Provider Demographics
NPI:1093771859
Name:GIBSON, ANGELA MICHELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:MICHELLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4515 SETON CENTER PARKWAY
Mailing Address - Street 2:SUITE 215-CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5785
Mailing Address - Country:US
Mailing Address - Phone:512-231-5548
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:4100 EVERETT DR
Practice Address - Street 2:SUITE 400
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6146
Practice Address - Country:US
Practice Address - Phone:512-295-1333
Practice Address - Fax:512-406-7327
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154127806Medicaid
TX8B5305OtherBC/BS
TX1541278-01Medicaid
TX154127805Medicaid
TX391131YKXVMedicare PIN
TX154127806Medicaid
TX154127805Medicaid
TX080180454Medicare PIN
TX8322B6Medicare PIN
TXH17066Medicare UPIN